Psychotherapy

Limitation of Diet .—Just as soon as a patient's attention is attracted forcibly to any tendency to constipation, he is almost sure to conclude that this is a symptom of indigestion and he proceeds to put into practice all the rules which he has heard and read for the treatment of indigestion. The first of these is elimination from the diet of all indigestible food products, including most of the vegetables. The result is a vicious circle of cause and effect by which constipation is rendered worse than before. This needs to be explained to intelligent patients in order to make them understand that some of the new habits which they have been forming and which they are prone to think highly hygienic, of cutting off all food containing indigestible material, are really important factors in the causation of further intestinal disturbance. It will often be found that the real reason for patients' inability to have daily evacuations of the bowels, is that they have become persuaded that various forms of food are either indigestible on general principles, or else are indigestible for them. For this reason they have eliminated from their diet most of nature's ordinary and quite natural provocations to intestinal evacuation, only to have to substitute artificial means to the same end in the form of the various laxatives.

It is important to talk this matter over with patients; otherwise the true cause of their constipation may be missed. For instance, from the very beginning of human life an excess of fat acts as a lubricant of the intestine, and as a material by means of which other and more concentrated objectionable matter that needs to be eliminated is carried out with as little friction as possible. Mother's milk contains from one-fourth to one-third more fat than the baby can use in its economy. This is meant to furnish a lubricant for the large intestine. It is a residue that will aid in securing movements of the bowels at regular intervals.

Fats .—Many people who come to their physicians complaining of habitual constipation have been told, or have read, that fat is rather indigestible, and, as a consequence, they have eliminated from their dietary all fatty materials. Even butter they use but sparingly, and they exchange the cream in their tea or coffee for plain milk; they carefully remove as much as possible of the fat of meat and they abstain from all sauces in which fat is employed. Such practices make normal, natural, regular evacuations of the bowels extremely difficult.

Sugars .—Another food material that is a valuable aid to nature for the stimulation of peristalsis is sugar. In its digestion, a certain amount of fermentation takes place, and the gas from this stimulates peristalsis. Of course, there may be excessive fermentation, and then harm rather than good, is done. Ordinarily a certain amount of sugar is demanded by nature and practically all the food materials, even the meats, contain it. All the starches from vegetables have, as the end products of their digestion, various forms of sugary material. These are just the classes of foods that many nervous persons, suffering from constipation and anxious about their digestion, eliminate from their diet under the mistaken notion that they are indigestible, or are productive of undesirable fermentations. When they do so, it is not surprising that their constipation should be emphasized and that they should have to ingest other irritant materials, laxatives, to replace the sugars. It is probable that where constipation exists in the bottle-fed infant, the addition of a little brown sugar to the water with which the milk is diluted, is the safest and most natural way of correcting the sluggishness of the intestines.

Supposed Idiosyncrasies .—The physician will in many cases meet with the objection that some of these materials that he is recommending disagree with his patient. Most of the presumed idiosyncrasies in the matter of food are founded on extremely insufficient evidence.

Not infrequently young persons who are thin and inclined to be constipated, and who need to take fats plentifully, do not care at all for butter. Sometimes this is founded on nothing more than the fact that at some time or other the butter provided for them was rather poor, and they got out of the habit of eating it. Now they assume that their disinclination is physiological. In this regard, as with milk, a little careful persistence will usually convince the person that there is no natural obstacle and no good reason why they should not partake, in moderate quantities at least, of this extremely valuable article of food.

Often the supposed idiosyncrasy against a food is due to no better reason than that on a single occasion it disagreed, owing to its preparation, the circumstances under which it was eaten, or the materials with which it was associated. An aversion, for instance, to so nutritious and so valuable a food-stuff as hog-meat will be acquired for no better reason than that fried ham or bacon disagreed with the patient on one or more occasions. Such people when told that ham, boiled so thoroughly that it crumbles in the fingers, is a favorite mode of giving meat to convalescents in European hospitals and that it agrees very well with them, will often be tempted to try it. Then they find they have been harboring an illusion as to their supposed idiosyncrasy for hog-meat. Nearly the same thing is true of bacon. A trial or two of crisp bacon, with the fat so thoroughly cooked out of it that it may be eaten out of the fingers without soiling them, will often convince those who doubt of their ability to eat it, how tasty a nutriment it is. Bacon is one of the most precious dietetic adjuvants in the treatment of constipation.

Exercise.—There is always a serious difficulty in the treatment of constipation in stout people. To counsel fats and starches and liquids in the quantities necessary to bring about regular natural movements of the bowels, through the mechanical presence of a sufficient amount of residue, will often add greatly to their weight. For them, exercises are needed. Not exercise in general, for many a man who takes abundant exercise may be constipated. I have patients with this complaint who are letter carriers, expressmen, even stevedores, and the like. The mere absence of a sedentary occupation will not guarantee against constipation. Motormen and conductors not infrequently suffer from it. What is needed particularly is exercise directed to the strengthening of the abdominal muscles, and the increase of peristalsis.

For this certain leg exercises that can be readily and easily done in less than five minutes each day will be found useful. A patient may be directed to lie on his back, lift up the leg as high as possible in the extended position, and do that with each leg an increasing number of times every day. At the end of a month he is able to lift each leg up forty or fifty times at each trial. This exercise twice a day, morning and evening, just before and after sleep, will usually relieve the constipation. The bringing up of the thigh on the abdomen as far as possible, not only acts as a sort of massage upon the abdomen itself, but the bellying of the large muscles within the pelvic and abdominal regions mechanically helps the movement of the intestinal contents. If, in addition to this, the patient gradually accustoms himself to rise to a sitting from a lying position, the constipation will almost invariably yield. In stout people, the presence of fat in the abdominal wall seems to weaken the muscles so that the intestines are not compressed as they should be in ordinary conditions, and peristalsis seems to be thus interfered with.

A heavy wooden (bowling) ball rolled on the surface of the abdomen, beginning low down in the right lower quadrant up towards the liver, across just above the umbilicus, and then down on the left is often advised. It is a good remedy but not better than the simple exercises of the leg and abdominal muscles suggested. The use of the ball has the advantage of novelty, and of distinctly adding to the suggestive value of the exercise treatment. It is particularly valuable for women. All of these exercises have a distinct value from their suggestive side. If thus twice a day for three minutes people are made to recall while doing the exercises the necessity for taking an abundance of fluid, forming a habit with regard to movements of the bowels and eating so as to encourage peristalsis, a definite good effect will be produced. In the treatment of stout people particularly, it is important to remember that the use of sufficient salt, and then of certain of the natural salts, as Carlsbad or Hunyadi Janos, may be of distinct advantage for their obesity. If taken regularly in small amounts, that is, just enough to help to a movement of the bowels, and if varied from time to time and occasionally interrupted while some other form of laxative is taken, much good may be done. It is as well to take simple irritants of this kind as some of the irritant foods that will have a tendency to add to their accumulation of fat, though they may increase peristalsis.

Influence of Position.—Little things may mean much in the matter of the regular movements of the bowels. In my student days in France, our little hotel in the Quartier had the old-fashioned water-closets consisting of a hole in the floor in one corner, and a place to put one's feet properly beside it, thus reverting to the old-fashioned natural method of bowel evacuation. Some of the American students found it an uncomfortable proceeding at the beginning, but, on the other hand, some of them who had suffered from constipation in America were no longer troubled that way. I have found in quite a few cases of younger men that the suggestion to revert to this natural mode of evacuation helped in the formation of the habit of having bowel movements at a regular time. How much of the effect was physical and how much was mental seemed hard to decide. The suggestion was particularly valuable in my experience with patients of the better educated classes.

CHAPTER VI

NEUROTIC INTESTINAL AFFECTIONS

There is a whole series of intestinal affections dependent on nerve influence that get worse and better under stress of emotion or relief from it. Probably the commonest of these is constipation, which is dealt with in a separate chapter. Often these nervous intestinal conditions are associated with other neurotic manifestations. On the other hand, patients are seen who are absolutely without any other sign of the neurotic habit, and have nothing like hysteria, yet who suffer severely and rather frequently from intestinal neuroses. Most of the people who react symptomatically to the eating of strawberries, or of shellfish, or of pork in any form, or cheese or other milk products, also have a definite tendency to certain skin neuroses and to suffer from intestinal troubles as a consequence of emotional states. It is hard to trace real causation in many of these cases, because it is so easy to accept the patient's expressions that they must have taken cold, or they must have eaten something that disagreed with them.

Neurotic Diarrhea.—But it must not be forgotten that nervousness alone, without any additional factor, may produce a disturbance of the functions of the intestines, and may even increase peristalsis and bring about severe diarrhea. Anyone who has observed students going to examinations has surely seen many examples of this. There are some individuals—fortunately they are rather rare—who always suffer from diarrhea when they have to take a serious examination. Some of these cases are pitiable because the effects are quite beyond control, and make it almost impossible for them to do justice to themselves.

Fright and Loss of Bowel Control .—Severe disturbance, such as fright, may bring on this paralysis of proper regulation of peristalsis, with consequent imperative intestinal evacuation. A classical case in history is that of James II, for whom the Irish soldiers invented a special name because of the tradition that he suffered from an intestinal accident in one of the battles with William of Orange. The imputation of cowardice on the last of the unfortunate Stuarts has been completely wiped out by the investigation of recent historians, and James' character for bravery has been thoroughly vindicated. The fact that the story should have gained credence shows that there is a general persuasion and popular tradition that such intestinal incidents do occur from fright. An incident told of the Franco-German War illustrates this, though I do not vouch for the facts. Wishing to test the bravery of some soldiers whom he was to send on a very dangerous expedition, and above all to try how they would bear up even before the threat of instant death, an officer of the French troops is said to have asked that half a dozen brave men be sent to him. Without a word, he announced that there had been treason in the ranks, and that the army needed an example. They were condemned to be shot. A platoon of soldiers was drawn up, the men were placed with their backs to a wall and they were asked whether they wished to be blindfolded. They refused though they protested that they did not know why they were being put to death. Then the word fire was given. All of the men, excepting one, fell down, though the guns of the firing party had been loaded with blank cartridges. The one who remained standing was told that he was the man who would be selected to go on the expedition, which, though perilous, was also of great glory for himself and profit for his country. He said that he was ready to go, but he asked permission to be allowed to change his clothing, as he had not been able to keep as good control over his intestinal muscles, as he had over his muscles of station.

Fright often has this effect in children. These stories and traditions illustrate the influence of the mind and of deep emotions over the intestines, and while only profound mental disturbance will produce the most serious effects, there seems no doubt that lesser emotions do interfere with normal function. This phase of the subject serves to strengthen the contention that over-attention to the bowels may bring about constipation by causing increased inhibition of peristalsis, just as severe emotional disturbance may paralyze inhibition and so bring about increased peristalsis with consequent diarrheal symptoms.

Habitual Diarrhea.—There are certain forms of chronic diarrhea, usually considered most intractable, that owe their origin and continuance to neurotic conditions of the intestine, rather than to any gross organic lesion. In these cases the bowels acquire the habit of emptying themselves two or three or more times a day, and the stools are seldom formed. All sorts of physical treatment are employed for these conditions, usually without avail, but whenever the patient's mind can be set at rest, and his attention distracted from his bowels by thorough occupation with some interesting work, the intestinal disturbance gradually becomes less annoying. Ordinarily, when stools have been frequent for a prolonged period, the case is considered more or less unamenable to treatment. So far as ordinary drug remedies go, this is true. What is needed is attention to the patient's mind, to his habits of life, and to his worries, and the way that he takes them. The illustrations given of the influence of the mind over the bowels should make it clear that this therapeutic principle can be of far-reaching significance and must be applied deliberately and with confidence in the results.

Worry as a Factor .—Very often it will be found that the diarrhea is particularly bothersome on days when the patient is worried. In a clergyman friend and patient who was building a church, the approach of days on which bills and notes became due, was always the signal for a diminished control over his bowels, and there were frequently three or four stools in the day. On his vacations, when eating unusual things, drinking unaccustomed water, exposed to changes of temperature, all the factors that give many people diarrhea, he was perfectly regular because the worries had been lifted from his mind. In another case, where for fifteen or twenty years a writer living much indoors had had tendencies to diarrhea, always made worse by worries, self-discipline and the refusal to let troubles occupy him by always turning to something else, did him so much good that he considered himself cured. In his case the return of a manuscript from a magazine would always affect his bowels unfavorably. If, as sometimes happened, he found that the manuscript had been returned only for some corrections, there would be an immediate relief of his condition.

Change of Mode of life and Intestinal Control.—An interesting phase of the neurotic or mechanical disturbance of peristalsis is found in the interference with regular movements of the bowels when persons are aboard trains for long distances, or for more than twenty-four hours. There are very few people who are not bothered in some way by such a journey. Those of a nervous temperament are likely to suffer from diarrhea. This is usually attributed to catching cold because of drafts, but in recent years, when well guarded Pullmans eliminate drafts to a great extent, the bowel disturbance continues. For the majority of people, however, constipation results. The cause of it seems to be due to a disturbance of peristalsis in the line of inhibition because of the vibration and jolting of the train. The more or less conscious assumption of definite positions of the muscles of the abdominal region in order to save the body from the action of the unsteady movement of the train, seems to be reflected in the sphere of peristalsis with consequent constipation. There are other features, such as a lessened consumption of food and water and absence of exercise, that seem also to have an influence. If the journey is for several days patients should be advised to walk out during the longer stops.

Mental Influence and Indifferent Remedies.—The best evidence that we have of the influence of mind upon the intestinal tract, and the importance of employing that factor for therapeutic purposes, is found in the number of cases of various intestinal disturbances, often apparently chronic in character, which have been cured by the administration of quite indifferent remedies. Dr. Hack Tuke in his "Influence of the Mind on the Body" reports a number of cases in which bread pills were used with good effect. Pillulae micarum panis were not an infrequent prescription in preceding generations. They are usually supposed to have been effective only against the curious symptoms that develop in hysterical women, but it must not be forgotten that neurotic manifestations connected with the abdominal region may occur very freely in men, and that treatment by suggestion in connection with some remedy, real or supposed, is the most efficient cure. The "British and Foreign Medical Review" for January, 1847, has a series of cases among naval officers which were reported by a surgeon of long standing and wide experience. These cases include painful intestinal psycho-neuroses, occasionally accompanied by diarrhea, and sometimes by constipation and sometimes even by dysenteric movements, all cured by bread pills when these were administered in certain definite ways, and the patient's attention concentrated on their expected effects. Bismuth lost its effect in one case of repeated colic, opium was beginning to lose its effect. The patient was then told that on the next attack he would be put under a medicine which was generally believed to be most effective, but which was rarely used on account of its dangerous qualities, and that would not be used unless he gave his consent. At the first sign of his next attack, a powder containing four grains of ground biscuit was administered every seven minutes while within the hearing of the patient the greatest anxiety was expressed lest too much should be given. The fourth dose caused an entire cessation of pain. On four other occasions, the same remedy was employed with equal success for the same sort of attack. In a seaman who was suffering from obstinate constipation which resisted even the strongest purgatives, including Croton oil, pills consisting of two grains of bread were administered every seven minutes, and the patient watched with very apparent anxiety lest an overdose should be given. Within two hours he began to have nausea at his stomach, which had been foretold as one of the symptoms to be expected, and his bowels were freely open almost immediately after. Apparently the administration of the bread pills eventually cured his constipation.

Skin and Intestinal Sympathy.—Curious intestinal conditions are, as I have said, often associated with neurotic manifestations of other kinds. Attacks of hives and other neurotic skin disturbances are common in association with nervous diarrhea. Sometimes the attack of hives precedes the intestinal disturbance; sometimes it accompanies it. Soon after eating the offending material, the skin manifestations may begin and other symptoms follow. Only a few minutes elapse, even when the patient does not know that the offending material has been eaten, because it is concealed in some combination, yet the reaction takes place evidently not from digestive absorption, but from intestinal reflex. Very often there is vomiting, as well as diarrhea. It is not hard to understand that in these cases there is produced an irritation of the intestinal mucosa, corresponding to that seen in the skin. Whenever this occurs, it is not surprising that there should be evacuation of the contents of the digestive tract in every way that nature has provided for removing irritating material. The simple nervous diarrhea is often spoken of as an "intestinal blush," as the neurotic disturbance of the bladder which causes frequent urination is spoken of as a "vesical blush." Blushing is certainly the external manifestation that corresponds most closely to the disturbance that is probably the basis of these curious manifestations.

Urticaria and Diarrhea .—Patients who suffer from urticaria readily are almost sure to have other neurotic disturbances, and their intestines seldom escape. On the other hand, those who have an idiosyncrasy for certain kinds of food are almost sure to have other nervous neurotic disturbances, which emphasize the fact that these curious idiosyncrasies are of reflex nervous origin, rather than due to any chemical irritation.

Some of these lesions of the intestinal tract related to urticaria may affect, either primarily or secondarily, the biliary structures. Under these circumstances there may be symptoms resembling true biliary colic with some jaundice and pain that radiates toward the right shoulder. Whether these bile symptoms are due to the occurrence of actual urticarial lesions in the bile duct, or so close to the papilla of entrance of the gall passages into the intestine as to occlude it, is doubtful. Practically all the symptoms of the presence of biliary calculus may be thus simulated. The differential diagnosis can only be made by the rapid clearing up of the symptoms, and by the history of the case. As a rule, where there is the story of repeated attacks of neurotic intestinal disturbance, the physician and especially the surgeon, should be slow to conclude as to the presence of a serious pathological condition anywhere in the intestinal tract, unless the symptoms are absolute. This is all the more necessary because now, in patients' minds, the words appendicitis or biliary calculus are associated with the thought of operation. This thought sometimes gives rise to so much dread as to seriously disturb the appetite and still further predispose the patient to the repetition of neurotic intestinal trouble.

In the chapter on Abdominal Discomfort, the necessity for absolute assurance of some definite lesion before there is any question of operation, is insisted on. Here the disturbing mental influence of suggestion, with regard to certain serious abdominal conditions, may be emphasized. Many painful conditions in the abdomen are either primarily or secondarily due to appendicitis. Most of these are quite acute, and practically all amenable to definite diagnosis. There is, however, a tendency to exaggerate the place that this organ holds in the pathology of chronic cases. Many women who suffer from nothing more than hysterical abdominal conditions are told by someone that they have recurrent attacks of appendicitis, though there is nothing except their suggestive complaints of pain on which to found such a diagnosis, and then it becomes extremely difficult to remove this idea from their minds, and contrary suggestion applied over a long period is the only therapeutics that favorably affects them.